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CT Neck Anatomy Demystified.Pdf CT neck anatomy demystified Poster No.: C-1588 Congress: ECR 2016 Type: Educational Exhibit Authors: I. Abreu1, D. Roriz2, P. Belo Soares3, Â. Moreira3, F. Caseiro Alves3; 1Porto/PT, 2Guimarães/PT, 3Coimbra/PT Keywords: Education and training, Diagnostic procedure, CT, Head and neck, Anatomy DOI: 10.1594/ecr2016/C-1588 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third- party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 26 Learning objectives Discuss the spaces of the deep core tissues of the suprahyoid and infrahyoid neck, as well as the oral cavity. Explore the anatomy of each space, presenting its limits, anatomy relationships and contents. Background Previously, the suprahyoid neck was divided into nasopharynx, oropharynx and oral cavity. Those spaces are still useful in the context of squamous cell carcinoma allowing its staging. However, the spaces of the suprahyoid neck as defined by the deep fascia cervical cut across the boundaries of the nasopharynx and oropharynx and some traverse into the infrahyoid neck. Therefore, the involvement of these fascia by diseases other than squamous cell carcinoma is poorly defined using this subdivisions. Currently, the suprahyoid and infrahyoid spaces are divided by the three layers of the deep cervical fascia (Table 1). Page 2 of 26 Table 1: Cervical spaces defined by the three layers of the deep cervical fascia References: Radiology, Centro Hospitalar e Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra - Porto/PT Findings and procedure details The suprahyoid neck consists in the region of the extracranial head and neck from the skull base to the hyoid bone. The remaining neck from the hyoid bone to the cervicothoracic junction is the infrahyoid neck. THE DEEP CERVICAL FASCIA The deep cervical fascia is composed by three layers that separate the supra and infrahyoid neck into fascia-defined spaces. Page 3 of 26 Superficial (investing) layer of deep cervical fascia This fascia envelopes the entire extracranial head and neck region from the skull base to the clavicles. In the suprahyoid neck it splits to enclose the parotid, masticator, and submandibular spaces. In the infrahyoid neck the superficial layer of deep cervical fascia invests the neck completely and splits as it runs posteriorly to encircle the sternocleidomastoid and trapezius muscles. A slip of this fascia also contributes to the carotid sheath. Middle layer of deep cervical fascia The middle layer runs on the deep surface of the strap muscles, but it merges anteriorly with the superficial layer of deep cervical fascia. It splits to encapsulate the thyroid gland. The posterior margin of the middle layer constitutes the anterior border of the retropharyngeal space. Other significant attachments of the visceral fascia include superiorly to the skull base and inferiorly with the deep layer of deep cervical fascia to the pericardium. A slip of the middle layer also contributes to the carotid sheath. Deep layer of deep cervical fascia The deep layer circumscribes and defines the perivertebral space, enveloping the prevertebral and paraspinal muscles, scalene muscles, vertebrae, vertebral artery and vein, phrenic nerve, and trunks of the brachial plexus. The deep layer of the deep cervical fascia attaches to the transverse process, subdividing the perivertebral space into anterior and posterior areas. • Anterior: The prevertebral aspect of the perivertebral space • Posterior: The paraspinal aspect of the perivertebral space Other significant attachments of the deep layer of deep cervical fascia include superiorly to the skull base and inferiorly with the middle layer of the deep cervical fascia to the pericardium of the mediastinum. A slip of the deep layer (alar fascia) contributes to the carotid sheath. All three layers of the deep cervical fascia contribute to the carotid sheath. The alar fascia also flares anteriorly to form the lateral wall of the retropharyngeal space. Page 4 of 26 THE SUPRAHYOID NECK SPACES 1 - PARAPHARYNGEAL SPACE (PPS) The parapharyngeal space (PPS) is the central space of the deep face an is surrounded by the pharyngeal mucosal, masticator, parotid, carotid, and lateral retropharyngeal spaces. Limits: The medial fascial margin ofthe PPS is made up ofthe middle layer of deep cervical fascia and the lateral fascial margin is formed by the medial slip of the superficial layer of deep cervical fascia. Posteriorly the PPS fascia is made up of the anterior part of the carotid sheath. The PPS is crescent-shaped in the craniocaudal dimension and extends from the skull base to the hyoid bone. Contents: • Fat • Branches of cranial nerve V • Internal maxillary artery • Ascending pharyngeal artery • Pharyngeal venous plexus Fig. 1: Parapharyngeal space boundaries References: Radiology, Centro Hospitalar e Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra - Porto/PT Page 5 of 26 2 - PHARYNGEAL MUCOSAL SPACE (PMS) The PMS is the area of the nasopharynx and oropharynx on the airway side of the middle layer of deep cervical fascia (buccopharyngeal fascia). Limits: Near the skull base the middle layer of deep cervical fascia (buccopharyngeal fascia) encircles the lateral and posterior margins of the pharyngobasilar fascia, the tough aponeurosis of the superior constrictor muscle that attaches it to the skull. More caudal in the nasopharynx and oropharynx, this middle layer surrounds the superior and middle constrictor muscles. The PMS is not completely fascia enclosed. Its posterior and lateral margins are defined by the middle layer of deep cervical fascia, but its airway side has no fascial margin. The bordering spaces of the PMS include the retropharyngeal space posteriorly and the PPS laterally. Contents: • Lymphoid tissue (adenoids, faucial and lingual tonsils) • Superior and middle constrictor muscles • Salpingopharyngeus muscle • Pharyngobasilar fascia • Levator palatini muscle • Torus tubarius 3 - THE MASTICATOR SPACE (MS) The superficial layer of deep cervical fascia splits along the inferior mandible, creating a sling that encloses the masticator space (MS). Limits: • Anterior: The buccal space (BS) • Posteromedial: parapharyngeal space (PPS) • Posterior: Parotid space (PS) The lateral slip of the superficial layer of deep cervical fascia runs over the superficial masseter muscle to the zygomatic arch and then cephalad over the temporalis muscle. The medial slip runs along the deep edge of the pterygoid muscles from the inferior mandible and attaches to the skull base. Its insertion on the skull base is medial to the Page 6 of 26 foramen ovale, so lesions extenting cephalad in the MS can enter the skull base through the foramen ovale. Fig. 2: Masticator space boundaries References: Radiology, Centro Hospitalar e Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra - Porto/PT Contents: • Muscles of mastication (Lateral pterygoid; Medial pterygoid; Masseter; Temporalis) • Inferior alveolar nerve • Ramus and body of mandible The parotid duct is not in the MS, but it passes just superficial to it as it courses over the masseter muscle. Lesions of the MS can involve the parotid duct by direct lateral invasion and mutually, lesions ofthe parotid duct may appear clinically as arising from the MS. The Buccal space (BS) has no true fascia boundaries. It is a region in close proximity to the MS and is often involved simultaneously with the MS when infection or malignancy is present. Contents: • Buccal fat pad • Facial artery and vein • Parotid duct (distal portion). • Buccinator muscle. Page 7 of 26 4 - THE PAROTID SPACE (PS) The superficial layer of the deep cervical fascia splits to envelope the parotid space (PS). Limits: The PS is the most lateral space in the suprahyoid neck, extending from the external auditory canal above to the level of the mandibular angle below. The posteromedial limit of the PS is the posterior belly of the digastric muscle and its fascia, which separates the PS from the carotid space. Directly medial to the PS is the parapharyngeal space. Contents: • Parotid gland • Facial nerve • Retromandibular vein • External carotid and internal maxillary arteries • Intraparotid lymph nodes 5 - THE CAROTID SPACE All three layers of deep cervical fascia condense to form the carotid sheath. It is a more substantive fascia in the extracranial head and neck that prevents disease outside the CS from entering and disease within the
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